Abstract
Background:
Urinary incontinence is common among older hospital inpatients and is associated with functional decline, skin damage, and delayed discharge. While guidelines recommend structured assessment and conservative management, continence care often remains reactive and inconsistent. This review uses behavioural science theory to explore the barriers and facilitators to implementing improvements in continence care for older people in acute hospital settings.
Methods:
A search strategy, across MEDLINE, EMBASE and EMCARE encompassed peer-reviewed literature from 2015–2025 using terms related to incontinence, the older adult and acute care settings. From 230 abstracts identified, 18 studies were selected for narrative review focusing on the barriers and facilitators to continence care within the context of the COM-B theoretical model of behaviour.
Results:
Several recurring barriers were identified. Staff shortages and time constraints limited the ability to deliver proactive continence care. Nurses reported lack of training, confidence, and support in continence assessment. Incontinence was often seen as inevitable or low priority. Practical challenges such as documentation burden, lack of bladder scanners, and difficulty maintaining individualised routines – especially for patients with cognitive impairment – were common. Cultural factors, such as ward norms favouring pad use, also hindered change. Facilitators included leadership support, involvement of healthcare assistants in routine toileting, visible success of interventions, and integration with wider care routines like intentional rounding.
Conclusion:
Improving continence care for older inpatients is not just a clinical issue – it requires cultural, educational, and organisational change. Implementation success depends on making continence a visible priority, empowering staff through training and leadership, and embedding routines into ward culture. Junior doctors have a role in advocating for proactive continence care and engaging with nursing colleagues to support meaningful change.
Comments
Thank you - it was helpful…
Thank you - it was helpful to think about this topic using the COM-B model. It really highlights the nuances of this difficult issue. Were there any particular areas of research around culture change of ward staff, as I think this is a big contributing factor to limiting improvements in continence during in-patient stays.
Culture change is a key factor in continence care
Thank you very much, Amanda, for your thoughtful comment. I completely agree that ward culture plays a central role in shaping continence care, and it’s an area where the COM-B model was particularly helpful in framing the evidence.
Several studies did highlight how task-focused ward norms often prioritise keeping patients “clean and dry” over promoting independence and continence. Artero-López et al. (2018), for example, described a degree of “inertia” in nursing care around incontinence, where pad use was normalised even when other approaches might have been possible. Staffing pressures and competing clinical priorities were also found to reinforce this reactive culture.
That said, there were some encouraging examples of change. Powell & Fenton (2023) described how structured tools and technology (such as prompts and bladder scanners) were used to shift ward routines and encourage a more proactive approach. O’Donnell et al. (2019) also emphasised the importance of co-design with staff and patients, helping to make continence care part of broader quality and safety conversations.
Overall, the evidence suggests that culture change is possible — but it requires sustained leadership, visible champions, and alignment with wider organisational priorities. Without these, continence care risks remaining a “hidden” task rather than being recognised as a fundamental component of dignity and safety for older inpatients.
Thanks again for raising such an important point.
Thanks
Thanks, I'll take a look at these studies. A co-design with patients and staff sounds like a really positive way to implement change.
good study- nice methodology
This poster is important as uses an under-used qualitative approach to the literature and focuses on multi-pronged potential approaches to improving care in acute hospital settings. It is also depressing as its all very recognisable!
Recognising the challenges, but also the opportunities
Thank you so much for this kind comment. I completely agree — much of what came through in the literature does feel very recognisable from day-to-day ward practice, which can be a little disheartening.
That said, I think the value of using a qualitative, behaviourally informed lens is that it helps to bring together the different strands — capability, opportunity, and motivation — and show that small, multi-pronged changes can add up. It won’t be easy, but it does highlight that culture, leadership, and practical tools all have a role in shifting continence care forward.
Question
Hello and thank you for your poster. This looks like it was a lot of work for you. Which one change do you think would provide the biggest win in improving continence in frail, older adults?
Thanks, that’s a great…
Thanks, that’s a great question. If I had to pick one change, I’d say the biggest win would be making proactive toileting part of routine ward care. Things like structured voiding programmes and intentional rounding — backed by leadership — really help shift continence from being seen as an afterthought to being part of patient safety and dignity. It’s not a single solution, but it’s probably the most impactful starting point.
Fab poster
My whole job centres around overcoming this culture great to see your poster! Thank you, Jen
Thank you
Thanks Jen, great to hear. Culture really does seem to be at the heart of the challenge, so amazing to know there are people like you working on it day to day. I’m glad the poster resonated with you!